challenges in suicide prevention for policy, practice and programme evaluation

Challenges in Suicide Prevention for Policy, Practice

and Programme EvaluationBrian L. Mishara, Ph.D., director

Centre for Research and Intervention on Suicide and Euthanasia (CRISE)Professor, Psychology Department

University of Quebec at Montreal (UQAM)[email protected] site: www.crise.ca

Wellington, New Zealand, 21 November 2007

mailto:[email protected]

http://www.crise.ca/

PLAN Our topic this morning: suicide has special characteristics that complicate and provide

challenges for programme evaluation, policy and practice• Brief history of suicide and explanation of suicide in about 5 minutes

– including, explanations of the relationship to mental disorders• How suicide is different from other problems and why these differences are important

for policy, practice and programme evaluation• A comment on appreciation of services: “perceived quality”• Some examples of programme evaluations in suicide prevention and their implications

– Two mental health promotion \ primary prevention programmes:• « I’m fed up» ( Plein le dos)• « Zippy’s Friends»

– Crisis intervention:• Evaluation of the 1-800-Suicide network in the USA• Comparisons of volunteers and paid staff

– Training: • Provincial training program of the Quebec Association for Suicide Prevention

– An intensive prevention programme in a workplace:• “Together for Life” suicide prevention programme of the Montreal Police Force

– An innovative programme to help high risk men who do not call helplines• Some comments on knowledge application• Conclusions• Recommandations

Brief history of suicide

and explanation of suicide in about 5 minutes…

Brief history of suicide and explanation of suicide in about 5 minutes

• Suicide– Has always existed


• Suicide– Has always existed– Occurs everywhere in the world

The burden of suicide

• 1,000,000 suicide deaths\year or more• 1 suicide every 40 seconds• Over 5-6 million bereaved by suicide• 20-100 million suicide attempts• Male rates greater, but less gender difference in lower &

middle income countries• More than 60% or world suicide deaths occur in Asia-

Pacific region• Pesticides responsible for 1\3 suicide deaths Suicide Suicide ––

among the top ten causes of death worldamong the top ten causes of death world--widewide•• The second most common cause of nonThe second most common cause of non--illness death illness death

worldworld--wide.wide.

Global burden of Suicide and other causes of violent death (relative

distribution)

14

12

38

35WarViolenceTraffic AccSuicide

WHO 2003


• Suicide– Has always existed– Occurs everywhere in the world– «Causes» have never changed, although

some factors have greater importance at different times and in different cultures

– People kill themselves to stop suffering


• Suicide– Has always existed– Occurs everywhere in the world– «Causes» have never changed, although

some factors have greater importance at different times and in different cultures

– People kill themselves to stop suffering– Mental health problems are an important risk

factor but are not sufficient to cause a suicide

Suicide and mental disorders

• Mental disorders (including alcohol and drug problems) are highly associated in Western countries (not as important in rural Asia, where impulsive unplanned suicides in acute crises are common)

• - but, relatively small proportion of persons with mental disorders will commit suicide

A•Bio-geneticVulnerability

+Negative Life

Events

BMental

Disorder

CStigma et

impactsDisinhibitionCognitive

DistortionsInsufficient \inappropriatetreatment

SuicideSuicideattempt

DCrisis

situationAvalability

of acceptablemeansLack of help,

social support Poor coping

skills

+


+Negative Life

Events

Prevention intervention

Future: identify vulnerable individualsPrevention of Negative Life Events


+Negative Life

Events

BMental

Disorder

Prevention - Intervention

TreatMental Disorders


+Negative Life

Events

BMental

Disorder

CStigma et



Prevention – InterventionReduce stigma & negative

impactsEducate caregiversEducate the general publicPromote best practicesCreate supportive

environments


+Negative Life

Events

BMental

Disorder

CStigma et



Prevention –Intervention-Crisis Intervention-Control access toMeans-Increase social Support-Teach effectiveCoping skills

DCrisis

situationAvalability

of acceptablemeansLack of help,

social support Poor coping

skills

+

How suicide is different from other problems and why these differences are important

• A rare event


• A rare event• relatively few people who intend to commit suicide die by

suicide– Cleaning my office– Suicide – most desperate suicidal individuals will not die by suicide

» 2-4% seriously consider suicide each year; 1-2% say they attempted each year;only 13.1 suicide deaths per 100,000 population in 2002–2004 in New Zealand ( .0131%)» Ambivalence; fear and hesitation, second thoughts

– generally “Prevention works”• Few persons who consider suicide seriously die by suicide –

they find other solutions– Prediction is impossible– Extensive programs will prevent few suicides


• Suicide is multi-determined• There are no simple solutions• There are numerous opportunities for

prevention activities


• Important ethical and practical issues for research

• Little empirical evidence that prevention programs work

• Opportunities for creativity abound


• Prevention activities always occur in an open system

• Unknown and unexpected factors may influence results

Are measures of perceived quality related to programme effects?

• Quality from whose point of view?– Clients always give positive evaluations– Helpers are missing key information– External criteria are necessary

Evaluation of «I’m fed up» (Plein le dos)

• General objective:– Long term: prevent suicides and attempts– Short term (too many):

• Help children develop more realistic conceptions of death;• Provide more accurate information on suicide;• Help children be aware of when they or their peers are

stressed;• Help children become more aware of how to resolve

problems and conflicts;• Help children become aware of confidants and resources;• Help children identify what makes life agreeable


• Objectives of the evaluation:– Determine if short-term goals are attained– Obtain information on children’s suicidal thoughts and

behaviours• Methodology:

– Interviews before, after and follow-up• Participants:

– Children age 11-12: 5 experimental groups (540 students) and 1 control group (183 students) in 3 regions of Quebec, 6th year of primary school


• Measures:– Interview questionnaires:

• Knowledge• Use of help• Suicide ideation and intentions

• Results:– Teachers and children adore the programme– No significant overall positive effects

• Explanation of results:– Too small dosage of intervention

Evaluation of «Zippy’s Friends»

• Developed by Befrienders International– Now distributed world-wide by the charitable

organization Partnership for Children• General programme objectives:

– Long term: prevent problems later in life (including suicidal behaviour)

– Short term: improve coping abilities and children’s adaptation skills

• Objectives of the evaluation:– Verify implementation of programme– Determine if short term goals were attained


• Methodology: – Implementation: session reports, interviewers,

multiple sources– Effects: pre-post observations+structured interviews

with children, comparisons to controls• Participants:

– First evaluation (1999-2000)• Denmark: Experimental Group 214 children (Kindergarten, 1st

grade and 2nd grade) Control Group, 109 children (Kindergarten, 1st grade and 2nd grade)


• Results:– First evaluation:

• Implementation: very successful, high appreciation and participation

• Effects: Improved social skills • Effects: no improvement in coping


• Interpretation of lack of improvements in coping in evaluation of original programme– Not enough content on coping nor enough

repetition and practice to help children master coping skills

– So, major revision and pilot testing before new evaluation study


• Participants:– Second evaluation of revised programme

(2000-2001)• Denmark:

– Experimental group 332 children, 1st grade; – Control group 110 children, 1st grade

• Lithuania: – Experimental group 314 children, Kindergarten – Control group, 104 children, Kindergarten


• Results:– Second evaluation:

• Implementation: very successful, high appreciation and participation

• Effects: significant increases in coping skills, social skills and decreased problem behaviours in Denmark and Lithuania

– One Year Follow-Up (Lithuania): Improvements maintained

Lessons learned from “I’m Fed Up” and “Zippy’s Friends”

• Having good goals and a well-conceived programme which is highly appreciated does not guarantee positive effects.

• However, programme evaluation can identify how to modify a programme in order to obtain the desired effects

• Zippy’s Friends now more than 100,000 children (and another 60,000 this year) in Denmark, Lithuania, England, India (Goa), Brazil, Poland, Canada, Norway, Iceland, Hong Kong, USA (New Jersey), Shanghai, and …. Ireland in 2008 and …

• New evaluation studies: decreased violence in Brazil, better adjustment to school transition in Lithuania, ongoing studies: school environment in Quebec and major longitudinal study in Norway

‘To help children and young people, throughout the world, develop skills which

will enhance their present and future emotional wellbeing.’

www.partnershipforchildren.org.uk

Evaluation of the 1-800-SUICIDE telephone network in the USA

• Contract from the American Association of Suicidology, grant from SAMHSA-USA government

• Objectives:– Determine how to evaluate the quality of telephone

help given over the national toll free 1-800-SUICIDE Hopeline network

– Determine if callers receive help according to agreed models of intervention and established practices

– Determine if certain intervention characteristics are related to more positive immediate call outcome

Evaluation of the 1-800-SUICIDE Hopeline in the USA

• Steps1) Determine models of intervention,

characteristics of “good” interventions and expected short term effects from:

• Interviews with centre directors• Literature review (research and clinical)• Questionnaires to all Hopeline centres• Verification with « experts »We identified 2 models – centres identify with

them


• Steps2) Develop reliable & valid Silent Monitoring Methodology

Methodology: • Silent Monitoring of 2611 calls • 2 persons monitoring each call

– Caller mood and changes, classification of content – Helper behaviour observations and ratings

• Variables based upon models and characteristics of “good practice” `(what “to do” and “not to do”)


4) Results:People in need call crisis centres in the networkCentre directors’ descriptions of what helpers do are

generally inaccurateEmpathy, respect, supportive attitude and establishing a

good contact are related to positive outcomesHelpers do not always ask (<50%) about suicide nor

complete risk assessments with suicidal callers


Results:The more directive Collaborative Problem Solving

Approach was related to positive outcomesActive listening approach is not related to positive

outcomesLives may have been saved“Unacceptable” behaviours occur in 15% of calls and

these may have negative consequences for callers Centres vary greatly in the nature and quality of

interventions and the extent to which there are positive outcomes


Recommendations:Need for continued quality control by monitoring callsHelpers should be selected for their empathy, respect

and ability to establish a good initial contactRisk assessment needs to be improvedTraining should emphasize a more directive

collaborative problem solving approach rather than active listening

There is a need to assess longer term impact with follow-up

Note: I will be talking more about this as well as differences between volunteers and paid staff tomorrow at 2pm in a parallel session

Evaluation of the provincial training programme of the Quebec Association for Suicide Prevention

• Objectives:– Determine if there are changes in attitudes,

knowledge and behaviours following participation in the three day training

• Methodology:– Design: pre-test, post-test, follow-up (4 months)

comparisons with Control Group on waiting-list– Measures: questionnaires on attitudes and

knowledge; role plays to evaluate intervention behaviours and intervention history in follow-up

– We validated that telephone role plays provide equivalent data to face to face role plays

How we measured intervention skills

Simulation : 3 role plays (3 « cases")– Ratings inspired by the Suicide Intervention Protocol (SIP)

by Tierney (1988)– 70 observations:

– Welcome (1 item)– Evaluation of suicide risk (10 items)– Analysis of the situation (24 items)– Repositioning (8 items)– The action plan (24 items)– Empathy– Respect– Intervention style (1 item)

• Of which, 32 items were considered “essential”

Evaluation of the provincial training programme of the Quebec Association for Suicide Prevention

• 1) Significant improvements in :– Attitudes:– Knowledge– Abilities– Feelings of Competence

• 2) Maintained improvements 4 months after training• 3) Attitudes, knowledge and feelings of competence were

relatively high before the training (attitudes 79% in pre-test, knowledge 65% in pre-test & feelings of competence 71% in pre-test)– Thus, improvements are modest

Training was revised to emphasize areas which need improvement and areas where abilities were high before training were given less emphasis

Comprehensive Police Prevention Program Effects

Normand Martin, Ph.D.

Suzanne Comeau, M.Ps.

Brian L. Mishara, Ph.D.

Director, CRISE

Program developed by:

Evaluation of the suicide prevention programme of the Montreal Police Force

• Police Force:– Total 4,157– Men 78%– Women 22%

–THEY ALL CARRY GUNS


• Programme objectives:– Prevent police suicides– Improve abilities of police to identify + help suicidal

individuals• Objectives of the evaluation:

– Verify implementation of the programme and its components

– Identify strength + weaknesses of the programme and its components

– Determine programme effects


• Four Principal Activities:– Promotion Campaign– Tour of the units– Training of Supervisors and Union

Representatives– Peer Police Support Line

Officers in trainingOfficers Officers in trainingin training


• Methodology:– For each component:

• Police-Resources (telephone help)– Focus groups, surveys, examination of call records

• Promotion campaign– Surveys

• Training Meetings at all Police Units– Focus groups, Questionnaires before and after training

• Training Union Representatives + Supervisors– Pre-post training questionnaires, 3 year later follow-up

• General: Focus groups interviews with key informers:– Programme committee, administrators, trainers, personnel


• Results + Conclusions:– Programme responds to

needs– Knowledge increases and

practices improved– 1-2 suicides per year

before programme; one 7 years after programme and 2 in 8th year

– 26 suicides 1980-19963 suicides 1997-2007

1980-1996 1997-2007


• Comments: – Methodologies must be adapted to the milieu– Success of a programme depends upon a

good understanding of the psycho-social environment

– Intensive programme may change longstanding trends in a small milieu

Comparison of pilot projects for family and friends of high risk suicidal men

• Challenge: high risk men (adults, who previously attempted, have mental health, alcohol or drug abuse problem) rarely call crisis centres and ask for help themselves– The “American hero mentality”– But, their family and friends (“third parties”) call when they

are concerned about them• Programme objectives:

– Prevent suicides and attempts in high risk men by providing programmes for family and friends who call Suicide-Action Montreal (Montreal area suicide prevention centre)

• Evaluation objectives– Compare the effects of different programmes offered to third

party callers at Suicide Action Montreal


• Methodology: – Random assignment to programmes– Evaluation pre-post + 6 month follow-up

• Participants– 131 family members of suicidal men who had

previously attempted, express suicide intent and have a mental health, alcohol or drug problem


• The programmes:– Information sessions (group)– Information sessions and an individual

telephone follow-up– “Direct Access:” meetings focussed on

referrals to mental health, alcohol or drug abuse services

– Telephone support (by specially trained volunteers)

– Family Therapy (dropped – refused by callers)


• Results:• Men were reported to have less suicidal ideation• Men made fewer attempts • Men were reported to have less depressive symptoms• Less psychological distress for third party• Better communication between suicidal person & family

members• Third party uses more positive coping mechanisms

– However, the objective of linking the suicidal men to resources was not attained


• More results:– The «Direct-Access» individual meetings

programme did not appear to work and there was insufficient participation in the family therapy programme

– The Telephone Support programme had more positive outcomes and was the most appreciated

– Adding a telephone follow-up to the information session did not improve results


– Conclusions• Programmes for family and friends are a promising

way to help high risk suicidal men who do not call crisis centres themselves

• Without a no-treatment control group we can not know for sure if spontaneous improvement would have occurred, but having a control group who receive no help would be considered unethical

• The Information Sessions and Telephone Support programmes are now offered to third party callers

ORGANIZATIONALCONTEXT of users

RECEPTIVITYAttitudesMotivation

EFFORTSin participation of the development of

the knowledgein acquiring the knowledge

in understanding the knowledge

INTERACTIONSresearcher-user

MEANS OFCOMMUNICATION

USEConceptuelInstrumental

Symbolic

EVALUATIONUtility

Credibility

RELATIONSHIPCAPITAL

DISSEMINATION BYRESEARCHERS

ability tocommunicate

effectively

PERCEIVEDCOSTS

EFFORTSto use theknowledge

Overall Conclusions

– Suicide is an important global problem, but not universally recognized, and suicide prevention is not sufficiently supported or funded (perhaps the situation is different in New Zealand?)

– Suicide prevention activities must be adapted for different age groups and different cultures.

– Most suicides are prevented; most desperately suicidal people find other solutions and do not attempt. Suicide Prevention usually works, and it is tragic when people do not find the help they need.

Overall Conclusions

• The evaluation of effects is useful, but it is better to link effects to process variables to better understand what is essential for the programme to be effective

• Measures of client satisfaction are great for convincing funding agencies to give money, but are useless for determining programme quality or effects

• The more homogeneous the target population and the more intense the activities, the more likely you are to identify changes in suicide rates

Some recommandations for policy, practice and evaluation

– Consider the full spectrum of suicidal behaviours as outcome measures, not just suicide mortality

– Think carefully about the programme theory, why doing this should prevent suicides– Begin by evaluating the implementation of programmes – any effects should be

related to the extent that programmes are implemented as planned and reach their target populations. For example, assess numbers and percentage of target populations affected by programmes, nature of activities initiated in comparison with what was planned, etc.

– Verify that sufficient numbers of at risk individuals are affected by the interventions.

– Examine intermediary variables that may indicate if programmes are functioning as planned: e.g. the extent of changes in attitudes, knowledge and practices of caregivers, compliance with referrals and treatment, changes in attitudes and behaviours of the population and target groups at risk, increases in collaboration among caregivers, etc.

– Examine the differential effects on various high-risk target populations, e.g. persons with previous attempts, chronic alcoholics, people with specific mental disorders, and other high risk groups in NZ.

– Conduct experimental comparisons of programmes and combinations of programmes in order to isolate what is helpful and what is not.

– Study how best to share the knowledge you acquire, assess how best to engage in knowledge application actitivies and evaluate their effectiveness

– Join the International Association for Suicide Prevention www.iasp.info

http://www.iasp.info/

Challenges in Suicide Prevention for Policy, Practice

and Programme EvaluationBrian L. Mishara, Ph.D., director

Centre for Research and Intervention on Suicide and Euthanasia (CRISE)Professor, Psychology Department

University of Quebec at Montreal (UQAM)[email protected] web site: www.crise.ca

Wellington, New Zealand, 21 November 2007

Attend IASP Congresses:2008 European Symposium, Glasgow, Scotland2008 ¸Asia-Pacific Regional Conference, Hong Kong2009 International Congress, Montevideo, Uruguay

www.iasp.info

mailto:[email protected]

http://www.crise.ca/

http://www.iasp.info/

challenges in suicide prevention for policy, practice and programme evaluation

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